Eur J Ageing (2007) 4:107–113 DOI 10.1007/s10433-007-0059-z
ORIGINAL INVESTIGATION
Preventive home visits to older home-dwelling people and different functional decline patterns M. Vass Æ K. Avlund Æ E. T. Parner Æ C. Hendriksen
Published online: 15 August 2007 Ó Springer-Verlag 2007
Abstract A preventive home visitation scheme has been part of Danish legislation since 1996. The aim of this study was to describe functional trajectories of older homedwelling people, and to identify whether education of the preventive home visitation staff and individual risk factors were related to specific functional decline patterns. The study is a secondary analysis of a population-based prospective controlled cohort study. Participation totalled 3,129 non-disabled 75- and 80-year-old men and women without mobility disability at baseline living in 34 municipalities. Self-reported functional ability was measured at baseline and after 1½, 3 and 4½ years follow-up. No functional decline was seen in 58% of the participants. A total of 17% developed catastrophic decline, 6% progressive and 7% showed a reversible decline pattern. The This study was supported by grants from the Danish Ministry of Social Affairs, the Danish Medical Research Council, the Research Foundation for General Practice and Primary Care, the Eastern Danish Research Forum, and the County Value-Added Tax Foundation and the Aase and Ejnar Danielsen Foundation. None of these funding sources have any involvement in study design, data collection, data analysis, interpretation of data, writing of the paper or the decision to submit for publication. M. Vass (&) Department of General Practice and Central Research Unit for General Practice, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen K, Denmark e-mail: [email protected] K. Avlund C. Hendriksen Department of Social Medicine, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark E. T. Parner Department of Biostatistics, Institute of Public Health, University of Aarhus, Aarhus, Denmark
remaining 12% showed mixed patterns. Education of the preventive home visitation staff was associated with a reduced risk of progressive decline, RR = 0.66 (CI 95% 0.50–0.86, p = 0.002). Not receiving home visits and living alone were associated with increased risk of catastrophic decline. Younger age (75 at baseline) was less associated with all decline patterns compared with older age (80 at baseline). Men had less risk of developing progressive, reversible and mixed decline patterns than women, but an increased risk of developing catastrophic decline. A feasible educational preventive staff intervention was associated with a reduced risk of progressive functional decline but not with other functional decline patterns. Early signs of functional decline may serve as an important trigger for when to intensify the search for and actively seek to ameliorate preventable conditions. Keywords Preventive home visits Older people Community intervention Education Functional decline Introduction The ultimate goal of preventive home visits and other kinds of preventive intervention in older persons is to optimize their health, well-being and functional status. Loss of mobility is an important functional outcome since it is part of western individualised culture to wish to remain independent as long as possible (Guralnik et al. 2001; Gill and Kurland 2003). Rather than focusing on bio-medical risk factors alone, preventive efforts should include several strategies to prevent disability (Ferrucci et al. 2001). Predictors of functional decline potentially amenable to intervention with documented effects may therefore facilitate the implementation of health promotion and prevention programmes for older people.
123
108
Preventive home visits to older people conducted by municipality-employed home visitors was introduced without specific guidelines by Danish legislation in 1996. They serve the dual purpose of supporting personal resources and offering social support aimed at preserving functional ability. After the law had been in force for a few years, many municipalities had come to recognize a need for more knowledge about the best way to carry out the visits and organise the programme. Preventive home visits in Denmark are most often carried out by district nurses, who are educated and trained according to the disablement process model (Verbrugge and Jette 1994) in the assessment situation. The disablement process is a model building on four mutually dependent critical age-related changes. This model defines disease as recognised biochemical and cellfunction abnormalities ascribable to a medical diagnosis. Organ impairment is defined as measurable, impaired functions of organs and the organ system that lead to specific symptoms and/or laboratory results. Functional limitations are restrictions in an individual’s basic physical and mental behavioural patterns necessary to uphold daily life. Disability reflects the consequences of physical and/or mental function limitation and may result in problems performing activities related to all aspects of life. Disability must incorporate expectations that depend on the individual’s economy, age and social situation (i.e. intra- and extra-individual modulating factors). In the preventive home visit situation, health, social and mental factors all need to be considered simultaneously to understand the disablement process of the particular individual. To supply this multi-facetted approach, recognition of ‘disability patterns’ may add important information to build into the preventive home visits and help target older people most in need of such an offer. A distinction between progressive and catastrophic (rapid-onset) decline has been proposed (Guralnik et al. 2001; Ferrucci et al. 1996; Onder et al. 2001; Ayis et al. 2006). Both kinds of decline are associated with increased mortality, but risk factors differ and it may therefore be useful to take the pace of disability into account, both in proactive and traditional clinical assessment schemes (Ferrucci et al. 2001). To our knowledge, no studies have described an association between different functional decline patterns and the education of primary care professionals engaged in preventive home visits. We therefore studied major patterns of functional ability over a 4½-year period on the basis of comprehensive longitudinal data on two age cohorts (75 and 80 years at baseline). The aim of this study was to describe functional trajectories in home-dwelling older people, and to identify whether education of the preventive home visitation staff
123
Eur J Ageing (2007) 4:107–113
and individual risk factors were related to specific functional decline patterns.
Methods The study is based on a secondary analysis of a populationbased prospective controlled cohort study with randomisation and educational intervention of home visitors and GPs at municipality level and outcome measured among the old persons living in the municipalities after 1½, 3, and 4½ years of follow-up. Detailed information about the study design has been published elsewhere (Vass et al. 2002).
Participants Altogether, 5,788 non-institutionalized citizens living in the 34 municipalities born in 1918 or 1923/1924 were invited. Addresses were drawn from the Civil Registration Office. Written consent was obtained from 4,060 persons (participation rate 70.1%). Twenty-two persons died and four were institutionalized before the intervention started (n = 4,034). To select an initially nondisabled cohort, we excluded 902 persons reporting need of help at baseline for at least one of the following activities: transfer, getting outdoors, walking indoors, walking outdoors in nice and poor weather and walking on stairs. Three persons droppedout, leaving 3,129 non-disabled participants for evaluation of functional patterns during 4½ years of follow-up.
Municipalities For inclusion in the study, municipalities had to offer preventive home visits according to the Danish legislation from 1998 which stipulates that all 75+-year-old should be offered in-home assessment twice a year. Not all municipalities had implemented this scheme at the beginning of the study in 1998. The municipalities also had to have and to offer fair or good rehabilitation and GPs should be able to collaborate within the scheme by contract. Consent to participation was obtained from 34 out of 50 eligible municipalities in four counties. No demographic differences were seen between these and the remaining 16 municipalities. Randomisation was carried out following paired matching of intra-county municipalities, urban/rural type, size and geriatric services (Vass et al. 2002). After randomisation there were no differences in baseline characteristics between intervention and control municipalities in terms of municipality size, population density, expenses per 75+ inhabitant, preventive home visitor staffing and the
Eur J Ageing (2007) 4:107–113
109
general collaboration between general practice and the home care systems.
Educational intervention among the health professionals in the municipalities Based on updated geriatric and gerontological documentation, all intervention municipality visitors received education and training focusing on assessment of functional ability at every home visit and coordinated interdisciplinary follow-up (Vass et al. 2002; Williams et al. 2002; von Renteln-Kruse et al. 2001).
Outcome measures among the old individuals living in the municipalities Need of help in daily activities according to the Mob-H Scale (Mobility-Help) (Avlund et al. 1996) was measured at baseline and at 1½, 3 and 4½ years of follow-up. The scale was formed by answers to questions about the following six activities: transfer, walking indoors, going outdoors, walking outdoors in nice weather, walking outdoors in poor weather and climbing stairs. The Mob-H Scale describes whether the participants perform the activities with or without help and counts the number of items performed without help. High scale values describe better function, six being the highest score (Fig. 1). In the present analyses the scales are trichotomized into person’s A theoretical model aggregating 3129 older persons into five functional trajectories during 4.5 years relating to the Mob-H scale
Score 6
severe mobility disability (need of help for more than two activities), moderate mobility disability (need of help for one or two activities) and no disability. Reliability tests on the Mob-H Scale showed agreement percentages from 98.1 to 100 and kappa values from 0.82 to 1.0 for the included items on intra-rater and inter-rater tests (Avlund et al. 1995). The construct validity of the included items has been tested in the Rasch model of item analysis (Avlund et al. 1996). Analysis of criterion-related validity concluded that mobility as measured by the scale was strongly associated with isometric muscle strength (Avlund et al. 1994), postural balance (Era et al. 1997) and physical performance (Avlund et al. 1994).
Functional decline patterns during 4½ years Functional decline patterns were derived after an algorithm based on functional ability measured at baseline, after 1½, 3, and 4½ years (Fig. 1). Non-decline was defined as no disability at all four assessments (Fig. 1a). Progressive disability was defined as a pattern of decline going from no disability at baseline via moderate disability to severe disability (Fig. 1b). Catastrophic disability was defined as a pattern of decline going from no disability to severe disability or death without moderate disability at any measurement (Fig. 1c). Reversible decline was defined as no disability at baseline, moderate or severe disability at 1½ and/or 3 years of follow-up and no disability at 4½ years follow-up (Fig. 1d). If disability trajectories could not be categorised according to these definitions, patterns were classified as mixed, which most often included both progressive and catastrophic decline patterns (Fig. 1e).
No disability
Covariates Moderate disability Score 4
Sever e disability Score 2
Baseline
1½ year
3 year
a) b) c) d) e)
4½ year
No decline n=817 Progressive decline n=208 Catastrophic decline n=522 Reversible decline n=218 Mixed pattern n=365
Fig. 1 Functional decline patterns. A theoretical model aggregating 3129 older persons into five functional trajectories during 4.5 years relating to the Mob-H scale
Covariates were: sex (specified from the Civil Registration Office), age (born in 1918 or 1923/1924). The 17 pairs of municipalities were based on the matched randomisation (1–17). Living alone was measured with a ‘yes’ or ‘no’ answer to a question asked at baseline, and persons accepting and receiving at least one preventive home visit during the 3 years of intervention were compared with persons not receiving preventive home visits (standardized municipality software).
Ethics The study complies with the Declaration of Helsinki and was approved by the relevant Regional Research Ethics Committees.
123
110
Eur J Ageing (2007) 4:107–113
Statistical analysis We used a generalized linear model for multinomial data to obtain the adjusted relative risk estimates. Adjustment for the cluster sampling was performed by including information on municipality pairs as a categorical variable in the model. All analyses were based on the intention to treat principle. Data were analysed using Stata Statistical Software: Release 9.0 (Stata Corporation 1999).
Results Among the initially non-disabled 3,129 older person’s no functional decline was seen in 58%. Seventeen percent developed catastrophic decline, 6% progressive decline and 7% showed a reversible decline pattern (Table 1). A total of 12% did not fell into these four categories and were categorised as mixed pattern.
Univariate comparison of the different functional decline patterns with selected covariates during the 4½ years of follow-up is shown in Table 2. Older adults living in intervention municipalities where the preventive home visitation staff received education and training had a reduced risk of progressive decline compared with older adults living in control municipalities (Table 3). Not receiving home visits was associated with increased risk of a catastrophic decline pattern and borderline significant associated with less development of progressive functional decline pattern compared with receiving at least one preventive home visit (Table 3). As expected, younger age (75 years of age) was less associated with all decline patterns compared with older age (80 years of age). Men had less risk of developing progressive, reversible and mixed decline patterns than women, but an increased risk of developing catastrophic decline. No major sex differences were seen between older persons with no functional decline (Table 3). Living alone was associated with increased risk of a catastrophic decline pattern.
Table 1 Frequencies of functional decline patterns in the 75-year and the 80-year cohort All
75-year-olds
80-year-olds
n = 3,129
Men n = 1,102
Women n = 1,216
Men and women n = 2318
Men n = 370
Women n = 441
Men and women n = 811
Pattern
%
%
%
%
%
%
%
Non-decline
58.1
64.0
61.9
62.9
46.5
42.4
44.3
Reversible decline
7.0
4.5
8.1
6.4
7.6
9.5
8.6
Mixed pattern
11.7
9.1
11.4
10.3
13.7
17.0
15.5
Progressive decline
6.6
2.8
8.0
5.5
5.4
13.4
9.7
Catastrophic decline
16.7
19.6
10.6
14.9
26.8
17.7
21.8
Table 2 Univariate comparison of different functional decline patterns during 4½ years with selected covariates Non decline n = 1,817
Reversible decline n = 218
Mixed pattern n = 365
Progressive decline n = 207
Catastrophic decline n = 522
All n = 3,129
Living in intervention municipality
953 (58.1)
118 (7.2)
201 (12.3)
89 (5.4)
278 (17.0)
1,639
Living in control municipality
864 (58.0)
100 (6.7)
164 (11.0)
118 (7.9)
244 (16.4)
1,490
Not received visits Received at least one visit
705 (57.1) 1112 (58.7)
77 (6.2) 141 (7.4)
130 (10.5) 235 (12.5)
65 (5.3) 142 (7.5)
258 (20.9) 264 (13.9)
1,235 1,894
75-year-olds
1458 (62.9)
148 (6.4)
239 (10.3)
128 (5.5)
345 (14.9)
2,318
80-year-olds
359 (44.3)
70 (8.6)
126 (15.6)
79 (9.7)
177 (21.8)
811
Men
877 (59.6)
78 (5.3)
151 (10.2)
51 (3.5)
315 (21.4)
1,472
Women
940 (56.7)
140 (8.4)
214 (12.9)
156 (9.5)
207 (12.5)
1,657
Living alone
730 (54.9)
96 (7.2)
165 (12.4)
115 (8.6)
224 (16.9)
1,330
Not living alone
1087 (60.4)
122 (6.8)
200 (11.1)
92 (5.1)
298 (16.6)
1,799
Values are given n(%)
123
0.008 1.25 (1.06; 1.49) 0.17 1.22 (0.92; 1.61) 0.95 (0.89; 1.01)
Generalized linear model for multinomial data. All analyses were adjusted for cluster effect (municipality pairs)
ORIGINAL INVESTIGATION
Preventive home visits to older home-dwelling people and different functional decline patterns M. Vass Æ K. Avlund Æ E. T. Parner Æ C. Hendriksen
Published online: 15 August 2007 Ó Springer-Verlag 2007
Abstract A preventive home visitation scheme has been part of Danish legislation since 1996. The aim of this study was to describe functional trajectories of older homedwelling people, and to identify whether education of the preventive home visitation staff and individual risk factors were related to specific functional decline patterns. The study is a secondary analysis of a population-based prospective controlled cohort study. Participation totalled 3,129 non-disabled 75- and 80-year-old men and women without mobility disability at baseline living in 34 municipalities. Self-reported functional ability was measured at baseline and after 1½, 3 and 4½ years follow-up. No functional decline was seen in 58% of the participants. A total of 17% developed catastrophic decline, 6% progressive and 7% showed a reversible decline pattern. The This study was supported by grants from the Danish Ministry of Social Affairs, the Danish Medical Research Council, the Research Foundation for General Practice and Primary Care, the Eastern Danish Research Forum, and the County Value-Added Tax Foundation and the Aase and Ejnar Danielsen Foundation. None of these funding sources have any involvement in study design, data collection, data analysis, interpretation of data, writing of the paper or the decision to submit for publication. M. Vass (&) Department of General Practice and Central Research Unit for General Practice, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen K, Denmark e-mail: [email protected] K. Avlund C. Hendriksen Department of Social Medicine, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark E. T. Parner Department of Biostatistics, Institute of Public Health, University of Aarhus, Aarhus, Denmark
remaining 12% showed mixed patterns. Education of the preventive home visitation staff was associated with a reduced risk of progressive decline, RR = 0.66 (CI 95% 0.50–0.86, p = 0.002). Not receiving home visits and living alone were associated with increased risk of catastrophic decline. Younger age (75 at baseline) was less associated with all decline patterns compared with older age (80 at baseline). Men had less risk of developing progressive, reversible and mixed decline patterns than women, but an increased risk of developing catastrophic decline. A feasible educational preventive staff intervention was associated with a reduced risk of progressive functional decline but not with other functional decline patterns. Early signs of functional decline may serve as an important trigger for when to intensify the search for and actively seek to ameliorate preventable conditions. Keywords Preventive home visits Older people Community intervention Education Functional decline Introduction The ultimate goal of preventive home visits and other kinds of preventive intervention in older persons is to optimize their health, well-being and functional status. Loss of mobility is an important functional outcome since it is part of western individualised culture to wish to remain independent as long as possible (Guralnik et al. 2001; Gill and Kurland 2003). Rather than focusing on bio-medical risk factors alone, preventive efforts should include several strategies to prevent disability (Ferrucci et al. 2001). Predictors of functional decline potentially amenable to intervention with documented effects may therefore facilitate the implementation of health promotion and prevention programmes for older people.
123
108
Preventive home visits to older people conducted by municipality-employed home visitors was introduced without specific guidelines by Danish legislation in 1996. They serve the dual purpose of supporting personal resources and offering social support aimed at preserving functional ability. After the law had been in force for a few years, many municipalities had come to recognize a need for more knowledge about the best way to carry out the visits and organise the programme. Preventive home visits in Denmark are most often carried out by district nurses, who are educated and trained according to the disablement process model (Verbrugge and Jette 1994) in the assessment situation. The disablement process is a model building on four mutually dependent critical age-related changes. This model defines disease as recognised biochemical and cellfunction abnormalities ascribable to a medical diagnosis. Organ impairment is defined as measurable, impaired functions of organs and the organ system that lead to specific symptoms and/or laboratory results. Functional limitations are restrictions in an individual’s basic physical and mental behavioural patterns necessary to uphold daily life. Disability reflects the consequences of physical and/or mental function limitation and may result in problems performing activities related to all aspects of life. Disability must incorporate expectations that depend on the individual’s economy, age and social situation (i.e. intra- and extra-individual modulating factors). In the preventive home visit situation, health, social and mental factors all need to be considered simultaneously to understand the disablement process of the particular individual. To supply this multi-facetted approach, recognition of ‘disability patterns’ may add important information to build into the preventive home visits and help target older people most in need of such an offer. A distinction between progressive and catastrophic (rapid-onset) decline has been proposed (Guralnik et al. 2001; Ferrucci et al. 1996; Onder et al. 2001; Ayis et al. 2006). Both kinds of decline are associated with increased mortality, but risk factors differ and it may therefore be useful to take the pace of disability into account, both in proactive and traditional clinical assessment schemes (Ferrucci et al. 2001). To our knowledge, no studies have described an association between different functional decline patterns and the education of primary care professionals engaged in preventive home visits. We therefore studied major patterns of functional ability over a 4½-year period on the basis of comprehensive longitudinal data on two age cohorts (75 and 80 years at baseline). The aim of this study was to describe functional trajectories in home-dwelling older people, and to identify whether education of the preventive home visitation staff
123
Eur J Ageing (2007) 4:107–113
and individual risk factors were related to specific functional decline patterns.
Methods The study is based on a secondary analysis of a populationbased prospective controlled cohort study with randomisation and educational intervention of home visitors and GPs at municipality level and outcome measured among the old persons living in the municipalities after 1½, 3, and 4½ years of follow-up. Detailed information about the study design has been published elsewhere (Vass et al. 2002).
Participants Altogether, 5,788 non-institutionalized citizens living in the 34 municipalities born in 1918 or 1923/1924 were invited. Addresses were drawn from the Civil Registration Office. Written consent was obtained from 4,060 persons (participation rate 70.1%). Twenty-two persons died and four were institutionalized before the intervention started (n = 4,034). To select an initially nondisabled cohort, we excluded 902 persons reporting need of help at baseline for at least one of the following activities: transfer, getting outdoors, walking indoors, walking outdoors in nice and poor weather and walking on stairs. Three persons droppedout, leaving 3,129 non-disabled participants for evaluation of functional patterns during 4½ years of follow-up.
Municipalities For inclusion in the study, municipalities had to offer preventive home visits according to the Danish legislation from 1998 which stipulates that all 75+-year-old should be offered in-home assessment twice a year. Not all municipalities had implemented this scheme at the beginning of the study in 1998. The municipalities also had to have and to offer fair or good rehabilitation and GPs should be able to collaborate within the scheme by contract. Consent to participation was obtained from 34 out of 50 eligible municipalities in four counties. No demographic differences were seen between these and the remaining 16 municipalities. Randomisation was carried out following paired matching of intra-county municipalities, urban/rural type, size and geriatric services (Vass et al. 2002). After randomisation there were no differences in baseline characteristics between intervention and control municipalities in terms of municipality size, population density, expenses per 75+ inhabitant, preventive home visitor staffing and the
Eur J Ageing (2007) 4:107–113
109
general collaboration between general practice and the home care systems.
Educational intervention among the health professionals in the municipalities Based on updated geriatric and gerontological documentation, all intervention municipality visitors received education and training focusing on assessment of functional ability at every home visit and coordinated interdisciplinary follow-up (Vass et al. 2002; Williams et al. 2002; von Renteln-Kruse et al. 2001).
Outcome measures among the old individuals living in the municipalities Need of help in daily activities according to the Mob-H Scale (Mobility-Help) (Avlund et al. 1996) was measured at baseline and at 1½, 3 and 4½ years of follow-up. The scale was formed by answers to questions about the following six activities: transfer, walking indoors, going outdoors, walking outdoors in nice weather, walking outdoors in poor weather and climbing stairs. The Mob-H Scale describes whether the participants perform the activities with or without help and counts the number of items performed without help. High scale values describe better function, six being the highest score (Fig. 1). In the present analyses the scales are trichotomized into person’s A theoretical model aggregating 3129 older persons into five functional trajectories during 4.5 years relating to the Mob-H scale
Score 6
severe mobility disability (need of help for more than two activities), moderate mobility disability (need of help for one or two activities) and no disability. Reliability tests on the Mob-H Scale showed agreement percentages from 98.1 to 100 and kappa values from 0.82 to 1.0 for the included items on intra-rater and inter-rater tests (Avlund et al. 1995). The construct validity of the included items has been tested in the Rasch model of item analysis (Avlund et al. 1996). Analysis of criterion-related validity concluded that mobility as measured by the scale was strongly associated with isometric muscle strength (Avlund et al. 1994), postural balance (Era et al. 1997) and physical performance (Avlund et al. 1994).
Functional decline patterns during 4½ years Functional decline patterns were derived after an algorithm based on functional ability measured at baseline, after 1½, 3, and 4½ years (Fig. 1). Non-decline was defined as no disability at all four assessments (Fig. 1a). Progressive disability was defined as a pattern of decline going from no disability at baseline via moderate disability to severe disability (Fig. 1b). Catastrophic disability was defined as a pattern of decline going from no disability to severe disability or death without moderate disability at any measurement (Fig. 1c). Reversible decline was defined as no disability at baseline, moderate or severe disability at 1½ and/or 3 years of follow-up and no disability at 4½ years follow-up (Fig. 1d). If disability trajectories could not be categorised according to these definitions, patterns were classified as mixed, which most often included both progressive and catastrophic decline patterns (Fig. 1e).
No disability
Covariates Moderate disability Score 4
Sever e disability Score 2
Baseline
1½ year
3 year
a) b) c) d) e)
4½ year
No decline n=817 Progressive decline n=208 Catastrophic decline n=522 Reversible decline n=218 Mixed pattern n=365
Fig. 1 Functional decline patterns. A theoretical model aggregating 3129 older persons into five functional trajectories during 4.5 years relating to the Mob-H scale
Covariates were: sex (specified from the Civil Registration Office), age (born in 1918 or 1923/1924). The 17 pairs of municipalities were based on the matched randomisation (1–17). Living alone was measured with a ‘yes’ or ‘no’ answer to a question asked at baseline, and persons accepting and receiving at least one preventive home visit during the 3 years of intervention were compared with persons not receiving preventive home visits (standardized municipality software).
Ethics The study complies with the Declaration of Helsinki and was approved by the relevant Regional Research Ethics Committees.
123
110
Eur J Ageing (2007) 4:107–113
Statistical analysis We used a generalized linear model for multinomial data to obtain the adjusted relative risk estimates. Adjustment for the cluster sampling was performed by including information on municipality pairs as a categorical variable in the model. All analyses were based on the intention to treat principle. Data were analysed using Stata Statistical Software: Release 9.0 (Stata Corporation 1999).
Results Among the initially non-disabled 3,129 older person’s no functional decline was seen in 58%. Seventeen percent developed catastrophic decline, 6% progressive decline and 7% showed a reversible decline pattern (Table 1). A total of 12% did not fell into these four categories and were categorised as mixed pattern.
Univariate comparison of the different functional decline patterns with selected covariates during the 4½ years of follow-up is shown in Table 2. Older adults living in intervention municipalities where the preventive home visitation staff received education and training had a reduced risk of progressive decline compared with older adults living in control municipalities (Table 3). Not receiving home visits was associated with increased risk of a catastrophic decline pattern and borderline significant associated with less development of progressive functional decline pattern compared with receiving at least one preventive home visit (Table 3). As expected, younger age (75 years of age) was less associated with all decline patterns compared with older age (80 years of age). Men had less risk of developing progressive, reversible and mixed decline patterns than women, but an increased risk of developing catastrophic decline. No major sex differences were seen between older persons with no functional decline (Table 3). Living alone was associated with increased risk of a catastrophic decline pattern.
Table 1 Frequencies of functional decline patterns in the 75-year and the 80-year cohort All
75-year-olds
80-year-olds
n = 3,129
Men n = 1,102
Women n = 1,216
Men and women n = 2318
Men n = 370
Women n = 441
Men and women n = 811
Pattern
%
%
%
%
%
%
%
Non-decline
58.1
64.0
61.9
62.9
46.5
42.4
44.3
Reversible decline
7.0
4.5
8.1
6.4
7.6
9.5
8.6
Mixed pattern
11.7
9.1
11.4
10.3
13.7
17.0
15.5
Progressive decline
6.6
2.8
8.0
5.5
5.4
13.4
9.7
Catastrophic decline
16.7
19.6
10.6
14.9
26.8
17.7
21.8
Table 2 Univariate comparison of different functional decline patterns during 4½ years with selected covariates Non decline n = 1,817
Reversible decline n = 218
Mixed pattern n = 365
Progressive decline n = 207
Catastrophic decline n = 522
All n = 3,129
Living in intervention municipality
953 (58.1)
118 (7.2)
201 (12.3)
89 (5.4)
278 (17.0)
1,639
Living in control municipality
864 (58.0)
100 (6.7)
164 (11.0)
118 (7.9)
244 (16.4)
1,490
Not received visits Received at least one visit
705 (57.1) 1112 (58.7)
77 (6.2) 141 (7.4)
130 (10.5) 235 (12.5)
65 (5.3) 142 (7.5)
258 (20.9) 264 (13.9)
1,235 1,894
75-year-olds
1458 (62.9)
148 (6.4)
239 (10.3)
128 (5.5)
345 (14.9)
2,318
80-year-olds
359 (44.3)
70 (8.6)
126 (15.6)
79 (9.7)
177 (21.8)
811
Men
877 (59.6)
78 (5.3)
151 (10.2)
51 (3.5)
315 (21.4)
1,472
Women
940 (56.7)
140 (8.4)
214 (12.9)
156 (9.5)
207 (12.5)
1,657
Living alone
730 (54.9)
96 (7.2)
165 (12.4)
115 (8.6)
224 (16.9)
1,330
Not living alone
1087 (60.4)
122 (6.8)
200 (11.1)
92 (5.1)
298 (16.6)
1,799
Values are given n(%)
123
0.008 1.25 (1.06; 1.49) 0.17 1.22 (0.92; 1.61) 0.95 (0.89; 1.01)
Generalized linear model for multinomial data. All analyses were adjusted for cluster effect (municipality pairs)
